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Vulnerable populations in ethnically diverse Toronto reported more discrimination by health care workers based on their housing status, mental health or substance abuse issues than race, a new study has found.

Forty-two per cent of people surveyed reported at least one form of perceived discrimination by health care workers, lead author Dr. Vicky Stergiopoulos wrote in a paper published in the journal BMC Health Services Research.

The most prevalent form of perceived discrimination was due to mental illness or substance abuse (33 per cent) and homelessness or poverty (30 per cent), said Dr. Stergiopoulos, psychiatrist-in-chief at St. Michael’s Hospital.

Only 20 per cent of non-Caucasian and 15 per cent of overall participants reported discrimination due to race, ethnicity or skin colour, said Dr. Stergiopoulos, who is also a scientist in the hospital’s Center for Research on Inner City Health.

Data for this research came from the Toronto site of the At Home/Chez Soi randomized controlled trial of providing safe, quality housing to homeless adults with mental illness to help them better focus on recovery.

All types of discrimination in health care settings were associated with more frequent use of Emergency Departments, a greater severity of lifetime substance abuse and mental health problems, Dr. Stergiopoulos said.

Perceiving discrimination of one type was associated with increased likelihood of perceiving other kinds of discrimination: those who reported discrimination due to homelessness or poverty were 32 times more likely to report discrimination due to mental illness or substance abuse. Those who experienced discrimination due to mental illness or substance abuse were almost nine times more likely to report discrimination due to race, ethnicity or skin color.

“The findings suggest that among ethnically diverse homeless adults with mental illness in a large urban center in Canada, perceived discrimination in health care settings in common,” Dr. Stergiopoulos said.

She said the most common complaint was a lack of respectful treatment by various practitioners.

“Discrimination can have a significant impact on the lives of those affected,” Dr. Stergiopoulos said. “The stress of perceived discrimination negatively affects mental and physical health, poverty and social marginalization, and may increase the likelihood of risky behavior. Discrimination by health care providers can be a key barrier to obtaining needed services, resulting in avoidance or delays in seeking treatment, under diagnosis and mistreatment, non adherence with or discontinuation of treatment and poor treatment outcomes.”

Dr. Stergiopoulos said understanding discrimination in health care is the first step toward designing policies and interventions to address health disparities among disadvantaged populations.

She noted that homeless people with mental illness are already among the most marginalized patient groups, reporting high levels of unmet health needs.

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Yesterday was annual World Suicide Prevention Day, which, given the recent high-profile suicide of the actor Robin Williams – a death that has generated a huge amount of media and professional debate on the subject – has an added layer of poignancy this year.

Although it may be disappointing that it requires the suicide of a much-loved celebrity to engage the media and public in such intense debate on the issue, as this feature investigates, the relationship of the media, celebrity suicide and suicide in the general population is fraught and complex.

First, some statistics. Last week, the World Health Organization (WHO) released some sobering data on suicide prevalence. According to the latest figures, one person commits suicide every 40 seconds.

“Suicides are preventable,” states WHO Chief Margaret Chan, who describes each suicide as an avoidable tragedy, and that suicide as a public health concern fails to grab attention because of taboos and stigma.

She adds:

“Every suicide is a tragedy. It is estimated that over 800,000 people die by suicide and that there are many suicide attempts for each death.

The impact on families, friends and communities is devastating and far-reaching, even long after persons dear to them have taken their own lives.”

The WHO report is the result of a decade of research involving 172 countries. It found that, in 2012, high-income countries had a slightly higher suicide rate than low- and middle-income countries, accounting for a quarter of the global toll.

The global rate was found to be 11.4 suicides among every 100,000 people, with men about twice as likely as women to complete suicide.

tributes to Robin Williams
Examining the outpouring of grief over Robin Williams’ death, we can see how seemingly innocuous statements may still present a violation of the established public health standards.

The report mentions that the most frequently used suicide methods are pesticide poisoning, hanging and firearms, with the exception of urban areas of Asia, where jumping from buildings is a common method.

However, the report castigates the media and users of social networks for providing lurid details of suicides and the methods used in reports of both celebrity suicides – such as Robin Williams – and unusual suicides by non-celebrities.

“Inappropriate media reporting practices can sensationalize and glamorize suicide and increase the risk of ‘copycat’ suicides,” the report states.

“Media practices are inappropriate when they gratuitously cover celebrity suicides, report unusual methods of suicide or suicide clusters, show pictures or information about the method used, or normalize suicide as an acceptable response to crisis or adversity.”

“Coverage of the recent suicide of Robin Williams was problematic,” Prof. Silvia Canetto, from the College of Natural Sciences-Psychology at Colorado State University, told Medical News Today.

“The reason,” she elaborates, “is that many journalists are not aware of the guidelines, and that training of journalists needs to be consistent, across generations of journalists, and with booster training opportunities.”

Media guidelines on suicide reporting

The “guidelines” she speaks of are perhaps not well known to the general public. In 1989, the Centers for Disease Control and Prevention (CDC) for the first time published recommended guidelines for news organizations on how to report on suicide.

newspaper printing press
In 1989, the CDC for the first time published recommended guidelines for news organizations on how to report suicide.

These recommendations were followed by similar guidelines from the National Institute for Mental Health (NIMH) and WHO.

What the guidelines are striving to prevent, is what experts term “suicide contagion.” Suicide contagion is a measurable phenomenon whereby sensationalized reporting of high-profile suicides is directly followed by a spike – on either a regional or national basis – in suicide attempts and/or completed suicides.

In the CDC’s own words, suicide contagion is “a process by which exposure to the suicide or suicide behavior of one or more persons influences others to commit or attempt suicide.”

The CDC’s position is that while suicide is often newsworthy and therefore likely to be reported, it is incumbent upon reporters to “understand that a scientific basis exists for concern that news coverage of suicide may contribute to the causation of suicide.”

For the CDC, this involves avoiding presenting simplistic explanations for suicide, sensationalizing or excessively repeating coverage, or reporting “how-to” details of suicide. Their guidelines also warn against glorifying people who commit suicide or “presenting suicide as a tool for accomplishing certain ends.”

The NIMH guidelines recommend that in media reporting on suicide, reporters should offer hope to readers, adding statements on the many treatment options and resources available for the psychiatric or substance abuse problems that they claim are present in 90% of people who have died by suicide.

Suicide contagion has been a public health concern since at least the 18th century, when the novel The Sorrows of Young Werther by Johann Wolfgang von Goethe was banned in much of Europe. Goethe’s titular lead character commits suicide following a failed love affair. The powers that be in these countries were worried that young romantics would take the character’s dilemma to heart, potentially sparking a wave of what are now known to the media as “copycat suicides.”

Despite this, there have been relatively few studies to comprehensively investigate suicide contagion. Some studies had found that – overall – suicide rates rise following an increase in media reporting on suicide, and that the greater the amount of coverage is, the greater the rise will be.

Corroborating the stance of the CDC and NIMH, these studies also suggest that media reports portraying suicide negatively are less likely to be followed by a rise in suicides. Goethe may be vindicated here, as studies have not yet reported a link between a rise in suicide and fictional accounts of suicide in the media.

However, the same studies have shown that reporting of the suicides of political or entertainment celebrities is followed by a rise in suicides.

‘Cluster suicides’ and suicide contagion

When a spike in suicide incidence follows a high-profile suicide, it is known as “a suicide cluster.” Teenagers are considered to be particularly at risk for cluster suicides.

depressed teenager hugging his knees
Teenagers are considered to be particularly at risk for cluster suicides.

Earlier this year, Medical News Today reported on a study in The Lancet Psychiatry that set about addressing the paucity of evidence on cluster suicides with an analysis of 469 American newspapers published between 1988 and 1996 and their relationship to 48 identified suicide clusters.

In each of these clusters, between 3 and 11 victims aged 13-20 killed themselves within 6 months of the first suicide.

The study – conducted by researchers from New York State Psychiatric Institute – reported that significantly more newspaper stories were published in the aftermath of a suicide that was closely followed by another suicide than those with no additional suicides within 6 months.

Also, the association was strongest for news stories about teenage suicides.

“Although we cannot show causality,” lead author Dr. Madelyn Gould explained, “our study indicates that media portrayals of suicide might have a role in the emergence of some teenage suicide clusters.”

This suggests that perhaps the CDC guidelines, which were first published at the start of that study’s investigation period, were not effective during their first 7 years of implementation. But have journalists and editors taken up the recommendations in following years? Evidence suggests not.

A 2010 study by Prof. Canetto, published in the journal Suicide and Life-Threatening Behavior, analyzed 968 local and national newspapers published in 2002-03 and concluded that American newspaper coverage did not follow the CDC’s updated 2001 guidelines on media reporting of suicide.

In particular, 56% of stories broke with the recommendations by describing the suicide method and 58% described location. Further contravening the guidelines, only 1% provided information about warning signs and risk factors for suicide, 4% highlighted the role of depression, 2% the role of alcohol, and only 6% recommended prevention-related resources.

The study by Canetto and colleagues could only find one instance of a high-profile suicide where these recommendations had been followed – the death of Nirvana singer Kurt Cobain, back in 1994.

How do the suicide reporting recommendations apply to modern media?

Since then, the media landscape has changed in ways that no one could have predicted, and so a new approach to how such guidelines might be applied to modern media may be required. Examining the outpouring of grief over Robin Williams’ death, we can see how seemingly innocuous and off-the-cuff announcements may still present a violation of the established public health standards.

screengrab of Robin Williams twitter tribute
A moving, appropriate epitaph, or irresponsible public statement?
Image credit: Twitter

This is perhaps best illustrated in the minor controversy over a tweet published by the Academy of Motion Picture Arts and Sciences following the announcement of Williams’ death. Posting a screengrab of the Williams-voiced genie character from Disney’s Aladdin, the Academy’s elegant 19-character tweet – “Genie, you’re free.” – seemed a moving, appropriate epitaph for a man who had been publicly plagued by mental health and addiction problems.

And it struck a chord with Williams’ fans – the message had been retweeted 361,624 times by the point the American Foundation for Suicide Prevention were quoted as saying the Academy’s tweet may contravene the guidelines by implying that suicide is an option.

With Twitter and other social media – increasingly people’s first stop for news and consensus views – beyond the scope of regulation, and with even trained journalists and editors not heeding the recommendations, to what extent are these guidelines either relevant or enforceable?

Silvia Canetto told MNT that the guidelines are still relevant but points to studies that show American journalists are “generally unaware that imitation suicide was a potential consequence of certain suicide reporting.”

For Canetto, the answer to preventing suicide contagion being spread by the media in the aftermath of high-profile suicides is to work with institutions responsible for training journalists and include education on suicide coverage as a component in their curriculums.

Secondly, Canetto argues that the awareness of and response to the guidelines by the media should be tracked to avoid the guidelines being disregarded if they come into conflict with “marketing journalism priorities.”

To what extent any lessons have been learned from the huge response to Williams’ death remains to be seen, but certainly – whether it is the American Foundation for Suicide Prevention’s response to the genie tweet, or recent newspaper think pieces on media complicity in suicide clusters – the issue of how we should talk about suicide is now being vigorously debated in mass media for the first time in 20 years, which can only be a good thing.

Written by David McNamee

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A new Australian study suggests rather than calling in sick and taking time off, depressed employees might find staying at work helps them better manage their illness.

businesswomen looking at an ipad
In the study, depressed employees who took sickness absence experienced no improved health or quality of life, whereas those who continued to work experienced health benefits.

Researchers from the University Of Melbourne, in collaboration with a team from the Menzies Research Institute at the University of Tasmania, report their findings in the journal PLOS ONE.

In their background information, they note previous research shows that while working through a depressive illness can improve mental health, it can raise risks and costs due to fatigue, poorer concentration and reduced job performance.

But what if, with good management, it was possible for employees with depression not only to benefit themselves, but also their employers by staying at work rather than taking sickness absence? This is where there is a big hole in the evidence base, say the authors, who set out to plug it.

Their study is the first to attempt to put into figures the estimated long-term costs and health outcomes of taking sick leave as opposed to continuing to work through depression-related illnesses.

Lead author Dr. Fiona Cocker, from Melbourne’s School of Population and Global Health, says you can’t expect to make recommendations to workers and employers without such information.

Study used ‘hypothetical cohort’ approach

For the study the researchers did not use “real” workers but an approach that is sometimes used in this type of investigation called the “hypothetical cohort.” This is a method that amasses features and characteristics typical of the target population (workers with depressive illnesses) from published studies and meta-analyses, and then uses a model to produce “results” under certain conditions.

A key component of this study was to define absenteeism (when the sick employee does not attend work for the duration of the illness episode) and “presenteeism” (when the sick employee continues to work for the duration of the illness) as mutually exclusive.

The data plugged into the model included probabilities and costs associated with seven different “health states” that members within the hypothetical 1,000-employee cohort might be expected to experience over the time horizon covered by the study (in this case, the researchers calculated figures for 1- and 5-year timescales).

These costs, included, where relevant, “lost productive time, job turnover, and health service use costs,” note the researchers.

Much of the data on probabilities and costs came from a primary Australian epidemiological data source, the National Survey of Mental Health and Wellbeing (2007). From this source, the team was also able to make some assessments about “subtle quality-of-life differences in areas including mental health.”

Depressed employees do not improve when off sick, but working ones do

What they found is that depressed employees who took sickness absence experienced no improved health or quality of life, whereas those who continued to work experienced certain health benefits.

They also found there were differences in the figures depending on whether the employees were white collar (office workers) or blue collar (manual workers), as Dr. Cocker explains:

“Cost associated with depression-related absence and attending work while depressed were also found to be higher for white collar workers who also reported poorer quality of life than blue collar workers.”

The researchers believe the findings are important not only for employers and employees, but also for GPs and other health care professionals providing support and advice on whether it would be better to continue working or stay at home during a depressive illness.

Mental health strategies should consider promoting continued working

Dr. Cocker says the findings indicate that “future workplace mental health promotions strategies should include mental health policies that focus on promoting continued work attendance via offering flexible work-time and modification of tasks or working environment.”

Having a daily routine and the support of co-workers could be one way that workplace programs and alterations can improve the long-term health and wellbeing of employees with depressive illnesses, she notes.

The researchers suggest their findings may also be useful for making recommendations concerning workers with other health conditions like diabetes and heart disease.

Medical News also recently learned how a new approach could revolutionize the care of depression in cancer patients, raising hope for the nearly three quarters of depressed cancer patients who do not receive any form of treatment for their depression.

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A team from McGill University has discovered that people who take the most common antidepressants (such as Celexa, Paxil, Lexapro, Prozac, and Zoloft, the Selective Serotonin Reuptake Inhibitors or SSRIs) are twice as likely to have dental implants fail as those who are not taking SSRIs.

“Because antidepressants, which are widely used around the world, are reported to increase the risk of bone fracture and reduce bone formation, we were curious to see how they might affect dental implants,” says Prof. Faleh Tamimi, the lead author on the study and a professor in McGill’s School of Dentistry. “Even so, we were surprised to discover that the negative effect of SSRIs on dental implants was so strong, almost equal to that of smoking, a well-established hazard for oral health.”

The researchers reached this conclusion by looking back over the records of dental implants done over a six-year period, between 2007 – 2013, in a clinic in Moncton, New Brunswick. Follow-ups took place with the patients between three and 67 months after the implant was done to see whether it had been successful.

“Unfortunately, because this study was based on data collected after the implants had been done rather than through interviews with incoming patients, it is impossible right now to determine the kind of SSRI dosage that could have this effect,” says Tamimi. “But what this study tells us is both that further work needs to be done in the field and that whether they are planning to have dental implants or hip or knee prostheses, SSRI users should consult their physicians and plan carefully to ensure that the surgical treatment is successful.”

The research was funded by the China Scholarship Council, Clifford Wong Fellowship, Canadian Institutes of Health Research, Institute of Musculoskeletal Health and Arthritis Bridge Funding, and Le Réseau de recherche en santé buccodentaire et osseuse.

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Housework just doesn’t scrub up as a physical activity that brings any mental health benefits, say researchers from Deakin University’s Centre for Physical Activity and Nutrition Research (C-PAN).

Two unique studies by C-PAN researchers Dr Megan Teychenne and Professor Kylie Ball have revealed that dusting, vacuuming and scrubbing the bath generate exertion and physical health benefits yet the monotony of the menial work brings no mental health rewards.

“Running, swimming and gym workouts all help people stay fit and mentally healthy and people who undertake these types of exercise are less likely to suffer depression,” Professor Ball said.

“But housework does not engender the same mental health benefits and shows no protective effects against symptoms of depression.”

In the first studies of their kind, Dr Teychenne and Professor Ball surveyed thousands of Victorian women about the amount and type of physical activity they undertook.

The studies aimed to identify associations between physical activity and the odds of depressive symptoms in women.

“To our knowledge, no previous research had compared leisure time, domestic and transport-related (walking and cycling) physical activity with odds of depressive symptoms in the same study,” Professor Ball said.

“Little research has been put in to what type of physical activity is most beneficial to good mental health and little is known about the optimal domain, dose and social context of physical activity for reducing the risk of depression.”

The first study, funded by the National Heart Foundation of Australia, surveyed 1554 women aged 18-65 from 45 Melbourne suburbs and all walks of life.

The second, funded by the National Health and Medical Research Council, surveyed 3645 women living in 80 socioeconomically disadvantaged Victorian neighborhoods in urban and rural areas.

“People living in disadvantaged neighborhoods are less likely to be regularly physically active than those from wealthier neighborhoods, which is why these areas were targeted in this study.”

The studies both found that women who reported walking or moderate intensity physical activity in leisure time were less likely to experience depressive symptoms.

But a surprise result also revealed that physical activity doing domestic chores contradicted the mental health benefits associated with exercise.

Professor Ball said the key finding of her research indicated the type of physical activity women get may be more important than the amount of exercise, when it comes to mental health.

Past findings have indicated that higher levels of physical activity were associated with lower odds of depressive symptoms, but that even just 30 minutes a week was linked with improved mental health.

“Our studies confirm previous findings that showed women’s moods were generally better when they were getting a workout in their leisure time.”

Professor Ball said the study also revealed the importance of the social aspects of exercise.

“Being a member of a sporting or recreational club, having someone to walk with in the neighborhood and being active with a family member are all associated with improved mental health,” Professor Ball said.

“This finding supports the dose of physical activity recommended in the US, UK and Australian national physical activity guidelines of at least two-and-a-half hours a week or at least 30 minutes on most, if not all days of the week.”

Whilst housework may not confer mental health benefits, it does provide physical health benefits and is a useful form of exercise for many people. “So ‘spring cleaning’ is still good for health,” she said.

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